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Medicaid Fraud Referral

Please complete this form with as much information and in as detailed a manner as possible. Upon receipt, your complaint will be reviewed by a member of our staff. A representative from the Pennsylvania Office of Attorney General, Medicaid Fraud Control Section, may contact you if additional information is needed
Complainant information (reporting person)
Name * Required
First Last
Email
Enter Email Confirm Email
Daytime Phone: * Required
Alternative Phone Number (Optional)
Address
Street Address City State Zip Code
County
Your Profession/Occupation
Have you contacted any law enforcement agency, insurance agency, or governmental agency regarding this complaint?
- Yes
- No
Agency that you contacted:
Type of Fraud/Complaint * Required
- Medicaid Fraud
- Abuse/Neglect/Mistreatment of Care-Dependent Persons
Medicaid Fraud
Patient Name
First Last
Patient’s Medicaid ID
Patient’s Managed Care Organization
Patient’s Date of Birth
MM slash DD slash YYYY
Patient’s Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
What type of Provider, Professional, or Facility is involved:
(check all applicable)
- Assisted Living Facility
- Nursing Facility
- Hospice
- In-Patient Mental Health Facility
- Physician
- Dentist
- Psychologist
- Nurse
- Nurse's Aid
- Personal Care Attendant (PCA)/ Direct Care Worker (DCW)
- Out-Patient Mental Health Facility
- Mobile Therapist (MT)
- Certified Peer Specialist
- Ambulance
- Lab
- Pharmacy
- Alcohol/Drug Treatment Facility
- Developmental Disability Facility
- Hospital
- Personal Care Home
- Chiropractor
- Pharmacist
- Nurse Practitioner
- Home Health Agency
- Behavioral Specialist Consultant (BSC)
- Therapeutic Staff Support (TSS)
- Therapist (physical, speech, occupational)
- Durable Medical Equipment
- Pain Management Clinic
- Transportation Company
- Other
Perpetrator of Criminal Activity
First Last
Estimated Age
Name of Provider/Professional/Facility * Required
Address of Provider/Professional/Facility
Street Address Address Line 2 City State Zip Code
Location of alleged fraudulent or criminal activity
(if different than the provider, professional, or facility address):
Date and time of alleged fraudulent or criminal activity:
Name of individuals with their job titles, if known, who were involved in fraudulent or criminal activity:
Name Title
Describe, in as much detail as possible, what a provider, professional, or facility did to commit Medicaid Fraud.
Abuse/neglect/mistreatment of care-dependent persons:
Abuse/Neglect/Mistreatment Type:
- Neglect
- Systemic Neglect
- Physical Abuse
- Sexual Abuse
Where did the alleged abuse/neglect/mistreatment of a care-dependent person occur?
Name of the facility/other location:
Address of the facility/other location:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Identify the type of facility, if known:
(check all applicable)
- Assisted Living Facility
- Nursing Facility
- Hospice
- In-Patient Mental Health Facility
- Developmental Disability Facility
- Hospital
- Personal Care Home
- Other
Other Facility
Did the abuse/neglect/mistreatment of a care-dependent person happen in a home or residence?
- No
- Yes
Home or Residence Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
If so, was the care-dependent person receiving attendant and/or personal care services at the time of the alleged abuse/neglect/mistreatment?
- No
- Yes
Name of patient/resident
First Last
Patient’s/Resident’s date of birth (if known):
Patient’s/Resident’s address (if known):
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Patient’s/Resident’s contact information (if known):
Your relationship to the patient/resident:
Date and time of incident:
Injury to patient/resident:
Medical treatment, if any, required (include the name of any hospital where treatment was rendered):
Name and job title of the person who allegedly abused, neglected or mistreated the patient/resident:
Name Title
Describe the incident in as much detail as possible:
If you would like to attach any additional documents to support this form, attach those documents below. Acceptable file types are images and PDFs. Max file size is 4MB and max total upload size is 10MB.
Supporting Documentation
Drop files here or

Max. file size: 100 MB, Max. files: 25.
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Date
MM slash DD slash YYYY

Section Resources

Print a referral form and send by mail

The Medicaid Fraud Control Section executive staff and intake team can be reached at the Pennsylvania Office of Attorney General Strawberry Square Headquarters in Harrisburg, PA, at (717) 783-1481.

The Medicaid Fraud Control Section also has three regional field offices throughout the Commonwealth: the Western Regional Office, the Central Regional Office, and the Eastern Regional Office. If you need to contact a specific region within the Medicaid Fraud Control Section, please use the following contact information:

Western Regional Office:
10950 Route 30, North Huntingdon, PA 15642; (724) 861-3670

Central Regional Office:
Strawberry Square, 7^th Floor, Harrisburg, PA 17120; (717) 712-1220

Eastern Regional Office:
1000 Madison Avenue, Suite 310, Norristown, PA 19403; (610) 631-5920

Name	Title

Medicaid Fraud Referral

Complainant information (reporting person)

Medicaid Fraud

Abuse/neglect/mistreatment of care-dependent persons: